TEALE FENNING

bronwyn · Posted: Sun Feb 11, 2007 5:25 pm Post subject: CGIN

Especially for you Raj....now you've read my little onco book!
Razz

A 38 year old woman is referred to the colposcopy clinic with a recent cervical smear showing atypical glandular cells suggestive of CGIN
a) discuss the possible implications of this smear finding
b) how would you go about examining the woman
c) discuss possible management options
d) she enquires about the effect of treatment on future pregnancies. How would you advise her?
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Bronwyn Bell
SpR
Portsmouth

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

a) discuss the possible implications of this smear finding
It's a rare report, involving only 0.1% of all smears performed
Glandular preinvasive disease is far less common than squamous (about 100 times)
It could reflect CGIN, or adenocarcinoma of the cervix or there could be endometrial cells
More risks for smokers and COCP users
Coexists with CIN in 2/3 of cases
HPV 18 more common causative agent (HPV 16 for squamous changes)
b) how would you go about examining the woman
Colposcopy: By experinced colposcopist. There are no typical features of CGIN. CIN may co exist in 2/3 of cases as I have already said. Lesions might be visible within 1 cm from the SCJ but there might be skip lesions higher in the endocervical canal (15%)
Hysteroscopy to exclude endometrial pathology with endometrial biopsy
c) discuss possible management options
If CGIN or CIN is confirmed in colposcopy, local treatment is still possible with LLETZ but has to be 25mm deep (instead of the 7mm routine for CIN) or knife cone biopsy. 40% risk of recurrence in women with involved margins, and 15% in women with clear margins (due to the skip lesions) therefore repeat procedure is likely.
This makes hysterectomy an option in women who have completed their families
When colposcopy and hysteroscopy normal review smear and MDT meeting. Repeat smear in 6 months
d) she enquires about the effect of treatment on future pregnancies. How would you advise her?
Most of the times outcome is good.
Increased risk of preterm labour, preterm rupture of membranes with LLETZ and cone biopsy
May require cervical length monitoring for shortening or wedging and possubly cerclage
No increased risk in subfertility or dysfunctional labour

bronwyn · Posted: Mon Feb 12, 2007 4:01 pm Post subject:

Like it Wolverine! Very Happy

Few things to add:
The incidence of cervical adenocarcinoma is increasing in both relative and absolute terms over the past two decades.
The natural history of cervical glandular intraepithelial neoplasia (CGIN) is less understood than that of squamous intraepithelial neoplasia (CIN), with which it is often associated. It affects the surface epithelium and the endocervical crypts and in some cases is discontinuous or multifocal.

Major limitations in colposcopic assessment of suspeced glandular lesions as severe pre-invasive glandular lesions such as HGCGIN have no typical colposcopic appearance. The only clue may be increased fragility or coexistant CIN.
There is an argument that loop diathermy is indicated in the assessment of smears showing glandular abnormality, as this is the only way to satisfactorily assess the endocervical canal. This would be an overreaction, as most mildly glandular smears need not reflect underlying dysplasia. Currently assessment includes
* Consideration of endometrial pathology and performing an endometrial sample
* endocervical cytobrush- if this provides further evidence of atypia then loop diathermy excision should be performed.

When invasion or severe glandular lesions suspected colposcopically histological confirmation is mandatory either by LLETZ or cone biopsy to attempt to remove the entire lesion.
In UK, national guidelines recommend that if early invasion is suspected, a designated pathologist with special interest in malignant gynae disease should examine the specimen.
When an early invasive lesion is suspected, a bimanual pelvic examination should be performed to exclude the possibility of local extension.
The sensitivity of a punch biopsy to detect glandular intraepithelial abnormality is poor due to lack of criteria for colposcopic recognition and to the finding that lesions may be confined to small area in the endocervix. Local ablation is not an ideal form of treatment.

Risk of cervical stenosis following cone.
Women who had a cone biopsy slightly more likely to have their babies born before 37 weeks. And the risk of low birthweight (less than 2,500g) a bit higher. Also an increase in birth by caesarian section for women who had cone biopsy.
LLETZ treatment showed a small rise in risk of birth before 37 weeks (pre-term delivery) and having a low birthweight baby (less than 2,500g). There was also a slight increase in premature rupture of membranes for women who had this treatment. The review also showed that the amount of cervical tissue removed affected risk. The risk of having a pre-term birth was higher for women who had treatment that was deeper than 10 mm.
_________________
Bronwyn Bell
SpR
Portsmouth

Nick Raine-Fenning · Posted: Thu Feb 15, 2007 6:44 pm Post subject:

Great question Bronwyn and an excellent answer wolverine.

This may be too technical for the exam as they seem to be moving to everyday situations and whilst this is not uncommon it is less common than an abnormal smear or repeated borderline / insufficient smears.

Anyway, if it does come up and you answer like this I guess you will get a 18-19 Wink

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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

Xerxes I · Posted: Tue Jul 29, 2008 1:57 pm Post subject:

This makes me nervous,

"CGIN is a bad thing to have" is as far as I would have gone! well may be I would have said the LLETZ and pregnancy bits but without numbers.

need to work harder